Limiting Principles for Social Determinants of Health
Should Medicaid pay the rent? Utilities? Transportation? Based on a social determinants of health philosophy, some policymakers think so. Burdening our broken healthcare system with new entitlements seems unproductive at best. As states venture into creating new programs, decision-makers need clear guidelines.
In 2003, the World Health Organization developed the field of social determinants of health (SDOH) research to understand how non-medical factors affect health outcomes. Researchers examined relationships between health outcomes and factors such as housing, poverty, transportation, racial discrimination, or education. Whenever any relationship was found, it became known as a “social determinant of health.”
Yet, understanding what does not qualify as a social determinant of health has become increasingly difficult. Theoretically, any correlative circumstance that affects health – mental health, environmental health, generational health, or financial health – could be included. Conventional wisdom holds that the longer a topic is researched, the more refined its definitions become. In the case of social determinants of health, the opposite holds true.
For SDOH, the United States Department of Health and Human Services provides “five pillars”: economic stability, education access, healthcare access, neighborhood and built environment, and social context. Currently, the initiative measures twenty-one “Leading Health Indicators,” which include a broad array of factors such as safe water, graduation rates, and bullying. Conceptually, the health indicators are meant to evolve, while the five pillars encompass anything that potentially affects health outcomes.
From a philosophical standpoint, if nearly all individual circumstances are connected to health, what qualifies as health or healthcare becomes meaningless. When confined to academic debates, such philosophical inquiries are relatively harmless. However, when vague concepts bear weight on policy, designing parameters for healthcare funding becomes problematic.
Abstraction makes it challenging to establish limiting principles for reasonable healthcare policies.
The more profound risk is far more unsettling. Tying an abstract SDOH framework to Medicaid policy can potentially wreck state and federal budgets. For states, Medicaid already consumes nearly one-third of every state budget, often representing the largest state expenditure. Since Medicaid is an entitlement program funded by federal and state governments, the budget expands to accommodate everyone who qualifies. Therefore, if one state has approved Medicaid waivers for food, utilities, or housing, the associated cost burden is effectively shifted onto that state and every American taxpayer.
Additionally, the state infrastructure for Medicaid is already administratively complex. No other payer in the country does health, developmental disabilities, skilled nursing, and other programs to assist the vulnerable. Adding SDOH duplicative programs would hurt those already receiving services with delays and additional costs.
Centers for Medicare and Medicaid Services (CMS) has provided some guardrails to Medicaid waiver programs for housing assistance. However, more research needs to be done to examine such programs’ efficacy and return on investment. Additionally, the waivers must not duplicate services already in place. Other agencies should consider reclaiming responsibility whenever a successful Medicaid waiver program exists.
Despite the dangers of fusing SDOH to Medicaid budgets, there are some circumstances where allowing non-healthcare-related Medicaid expenditures is reasonable for overall cost-savings, efficacy, or access.
For example, providing Medicaid waivers for behavioral health services for severe mental illness or opioid treatments could potentially reduce the overall number of ER visits. Investing in behavioral health is cost-effective when weighed against the overall costs of an untreated population. Said differently, behavioral health is health and clear definitionally within the healthcare continuum of care. The same cannot be said for other SDOH.
With the current technological infrastructure for data sharing between government agencies, collecting uniform data across states for issues like food insecurity or transportation has proven complex. As a result, the CMS implemented a new requirement for health practitioners to ask patients about five SDOH. Though healthcare practitioners are uniquely positioned to gather that data, special care must be taken so that the requirement does not become administratively burdensome.
Given the potential benefits and dangers of an SDOH framework tied to Medicaid policy, this blog series seeks to:
- Present limiting principles for SDOH in healthcare policy
- Uncover misleading information or erroneous claims in the literature
- Examine the ROI and efficacy of existing waiver programs
- Provide alternative, innovative solutions to policies better addressed by private organizations or other existing government entities
Though addressing social determinants of health through Medicaid is well-intentioned, states risk overwhelming an already dysfunctional healthcare system and putting vulnerable citizens at greater risk. Prudential decision-making requires limiting principles, accurate information, sound investment, and creative solutions.